Provider Demographics
NPI:1649669524
Name:VANVALKENBURGH, ALICIA
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:VANVALKENBURGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4711 NEW CENTRE DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28405-3442
Mailing Address - Country:US
Mailing Address - Phone:910-395-0749
Mailing Address - Fax:910-473-5546
Practice Address - Street 1:4711 NEW CENTRE DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28405-3442
Practice Address - Country:US
Practice Address - Phone:910-395-0749
Practice Address - Fax:910-473-5546
Is Sole Proprietor?:No
Enumeration Date:2015-01-15
Last Update Date:2015-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC19426183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician